Provider Demographics
NPI:1063996205
Name:MATTHEWS, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11358 VAN CLEVE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-1131
Mailing Address - Country:US
Mailing Address - Phone:314-968-2350
Mailing Address - Fax:314-533-6047
Practice Address - Street 1:11358 VAN CLEVE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-1131
Practice Address - Country:US
Practice Address - Phone:314-968-2350
Practice Address - Fax:314-533-6047
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022040516101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health